Enrollment Package

2211 St. Andrews Blvd.,

Panama City, FL 32405

850-215-2614

Student’s Name ______

Areas:

Family Information

Student Information

Medical Information

Educational and Therapy Information

Functional Behavioral Assessment

Student Learning Level Assessment

Student Reinforcement Inventory

Student Narrative

Expectations

Supplemental Information

Date Received: ------/------/------

Parent/Guardian Name______

First M.I. Last Relationship to child

Home Address ______

Address City St Zip

Home Phone (___)______Work Phone(___)______

Cell Phone(___)______E-mail Address______

Parent/Guardian Name ______

First M.I. Last Relationship to child

Home Address______

Address City St Zip

Home Phone (___)______Work Phone(___)______

Cell Phone (___) ______E-MailAddress ______

SS# of Parent Filing McKay:______

Sibling Name ______

First Last Age

Sibling Name ______

First Last Age

Sibling Name ______

First Last Age

Student Name______DOB______Age______

First Middle Last

Nickname__________Sex: M F SS#______

Home Address ______

Address City State Zip

Student’s Primary Diagnosis______Date of Diagnosis______

Secondary Diagnosis ______Date of Diagnosis______

Other Diagnosis______Date of Diagnosis______

Other Diagnosis______Date of Diagnosis______

Does the Student have any allergies? YES NO Please list any special dietary needs/concerns:

If so, please list/explain below: ______

______

______

Is the student currently on any medications? YES NO

If yes, please list medications below:

Type of Medication / Dosage / Administration Time / Purpose

Have there been any recent changes in medication? YES NO

If yes, Please explain ______

______

Has the student ever been admitted to a hospital or treatment center? YES NO

If yes, Please explain______

______

Are there any medical conditions to consider when delivering ABA services? YES NO

If yes, Please explain ______

______

Are there any other medical treatment interventions? YES NO

If yes, please explain ______

______

Student’s Primary Physician ______

Please list the services the student is currently receiving (or the last attended):

Public School (K-12) School Name ______County______

Grade ______ESE Current IEP

Services: OT PT SPEECH OTHER: ______

Private School (K-12) School Name ______County______

Grade ______ESE Has Current IEP

Services: OT PT SPEECH OTHER ______

Pre-School or Daycare Name of Program______

Home School -- Provided by School Provided by Therapist Provided by Parents

Early Intervention Program Services: ______

Other Therapies or Previous Services:______

______

______

Please list the student’s behaviors that interfere with learning or make them less successful at home:

Attention Seeking Behaviors
Physical Aggression
Self Stimulatory Behaviors / Non-Compliance
Self Injurious Behaviors
Throwing/Dumping Objects / Whine/Cry/Yell
Property Destruction
Elopement/Running Away

Please describe these behaviors: ______

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Please describe the frequency of these behaviors (How many times per day/week, etc.)______

______

______

Are there situations where the behavior is most likely to occur? ______

______

______

Are there situations where the behavior is least likely to occur? ______

______

______

How are you currently dealing with the behaviors? ______

______

______

Please answer the following questions regarding the student’s problem behaviors:

Please complete the following assessment of your child’s current learning level. Please circle the number that best describes your child’s current level for that area. You may also provide additional comments in the space provided.

  1. Cooperation in Instruction:
  1. Always avoids work and is uncooperative w/adults
  2. Will look at reinforcing or common items when presented
  3. Will allow reinforcing items to be removed
  4. Will do 1 brief response for powerful reinforcement
  5. Has multiple items or activities that act as reinforcement
  6. Can engage in 5 responses without escape behaviors
  7. Can work for 1 minute without escape behaviors
  8. Can work for 5 minutes without escape behaviors
  9. Can work for 10 minutes without escape behaviors
  10. Task completion serves as reinforcement for work
Comments:______
______/
  1. Receptive Language:
  1. Shows little to no receptive understanding of others
  2. Is selective in receptive compliance to others
  3. Will follow instruction to do reinforcing activity
  4. Will follow instruction to do simple action(sit down, etc)
  5. Follows instruction related to daily activities
  6. Will receptively identify items by pointing to them
  7. Will receptively identify items from an array of items
  8. Receptively identifies body parts
  9. Can select items when told the feature, function or class
  10. Follows multiple component sequence of instruction
Comments:______
______
  1. Imitation Skills:
  1. No imitation of other’s motor movements
  2. Motor imitation using objects such as a car or other toy.
  3. Motor imitation of gross motor movements
  4. Motor imitation of arm and hand movements
  5. Motor imitation of leg and foot movements
  6. Motor imitation of head movements
  7. Motor imitation of mouth or tongue movements
  8. Imitates the speed of motor movement
  9. Motor imitation of fine motor movements
  10. Imitation of a sequence of actions
Comments: ______
______/
  1. Vocal Response:
  1. Makes little to no vocal sounds
  2. Makes just a few speech sounds
  3. Will sometimes say an approximation of a couple of words
  4. Can imitate some basic sounds reliably when requested.
  5. Can imitate consonant or vowel blends when requested
  6. Imitates some approximation of words when requested
  7. Can imitate any word clearly when requested
  8. Can imitate 2-word combinations when requested
  9. Can imitate any phrase when requested
  10. Can imitate varying intonations and prosody
Comments:______
______
  1. Requesting for Items or Activities:
  1. Only engages in inappropriate behavior to indicate needs
  2. Will pull, drag or point to indicate desired items or activities
  3. Can appropriately request 2-3 items with many prompts
  4. Can request for many items/activities with prompts
  5. Readily and reliably request when asked “What do you want?”
  6. Spontaneously request for many items with one word
  7. Requests for many items with 2-3 word phrase
  8. Often requests for items/activities using a full sentence
  9. Request for information using Who, What, Where, etc.
  10. Request using adjectives, prepositions, pronouns, etc
Comments:______
______/
  1. Labeling Items or Properties:
  1. Cannot label items using a sign or a vocal response
  2. Can label some reinforcing items
  3. Can label some common items
  4. Can label some people
  5. Can label some actions
  6. Can label some colors or other adjectives
  7. Can label some body parts
  8. Can label some items using yes and no
  9. Can label items, events and properties using a sentence.
  10. Can label emotions of self and others
Comments:______
______
  1. Responding Conversationally:
1. Cannot fill-in words from simple songs or phrases
2. Can fill-in a few words from simple questions about self; name, age, etc.
3. Answers some simple questions about self; name, age, etc
4. Can fill-in items when told it’s feature or function
5. Can state the class of items like furniture, food, etc.
6. Can answer some questions like who, what, when, etc.
7. Answers Can, Do, Does, Will questions with yes or no
8. Can answer some questions about future or past events
9. Can answer academic questions
10. Maintains a conversation with adults
Comments: ______
______/
  1. Social Interactions:
  1. Makes little to no attempt to interact with others
  2. Is appropriate when near siblings or peers
  3. Shows interest in the behavior of others
  4. Approaches and attempts to interact with others
  5. Will make good eye contact only with some people
  6. Makes good eye contact sometimes with adults and peers
  7. Will reliably return greeting to others
  8. Will reliably initiate greeting to others
  9. Will give up items or wait turn only with adults
  10. Will take turns and give items when interacting with peers
Comments:______
______
  1. Academic Skills:
  1. Cannot identify any letters or numbers
  2. Can identify some letters
  3. Can identify some numbers
  4. Can write some approximation of letters and/or numbers
  5. Can identify ALL letters
  6. Can identify ALL numbers 1-20
  7. Can identify some sounds of some letters
  8. Can read simple words
  9. Can spell some simple words
  10. Can read fluently, spell words and add some numbers
Comments:______
______/
  1. Independent Functioning Skills
  1. Is not toilet trained and is in diapers
  2. Needs assistance in dressing and grooming
  3. Needs assistance feeding self
  4. Can eat some finger foods by self
  5. Can use a spoon and or fork with some assistance
  6. Can independently feed self
  7. Can stay dry if taken on a schedule to the toilet
  8. Can spontaneously request to use the toilet
  9. Can independently use the restroom
  10. Can independently dress and groom self
Comments:______
______

Please fill in the chart below based on the Student Learning Assessment found above and on previous page.

Please list the items and activities that appear to be preferred by the student

Preferred edible item(foods/snacks)______

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Preferred drinks ______

Preferred video or music ______

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Preferred games or toys ______

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Preferred indoor activities: ______

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Preferred places to visit: ______

______

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What does the student spend most of free time doing at home? ______

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What does student spend reinforcing about current educational environment______

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Please provide some background information about student and his/her current functioning, cooperation, learning level, educational development, social development and ability to communicate with others. Please include the student’s strengths along with his/her deficits.______

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Please provide some of your expectations for your child for his/her growth and development:

______

Please provide additional information enclosed or attached to the enrollment package

_____Student’s current or most recent Individual Education Plan

_____Other Psychological or Educational Evaluations

_____Other applicable medical evaluations

_____Video: If possible, please bring a video or the student at home, in his educational environment or participating in other relevant therapies. It would be best to see the student engaging in language or other skill areas. Do not be afraid to capture some of the student’s problem behaviors that he or she may engage in. If possible, please provide the video in DVD format.